Fillable Protected Health Information Amendment - Notification Form (Cameron University)

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Protected Health Information Amendment - Notification Form (Cameron University)

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________________________________
Cameron University
Employee Health Plan
Protected Health Information Amendment - Notification Form
I request and authorize Cameron University’s Health Plan to notify the individuals or entities listed below of the
amendment(s) made by the Health Plan to the medical records of:
Name of Member
Signed:
Name
Title, if legal representative *
Date
*
May be requested to submit evidence of representative status.
Individuals/Entities Who Need to be Notified of Amendment:
Name: Name:
Address:
Address:
Name: Name:
Address:
Address:
Name: Name:
Address: Address:
OFFICE USE:
Name/Title of person who completed request:
Date Request Completed
:
HIPAA Document
Rev. 1/2015 © 2015 File in Member Chart Retain for a minimum of 6 years
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Protected Health Information Amendment - Notification Form (Cameron University)

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Completed 22 July 2020

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